First Report of Injury Form

Instructions

Important: You cannot begin this form, save, and return later to finish and submit.
Please gather all information before starting the form. Provide as much detail as possible to avoid delays.

Information we need. Employer’s name, Employee’s name, address, phone number, Social Security number (or other ID type), date of birth, date first employed,
date of injury, date of disability (if one), wage rate, normal hours worked, description of how the injury occurred, the body part and type of injury, type
of medical treatment sought, and the medical provider visited.

Logged in users: If interrupted while completing the FROI and your browser is inactive for 30 minutes, your session will time out and you
will lose all data entered.

Concerns or additional information. Use the comments box or attach a statement with your concerns. Attach supporting documents like a work
release, wage information, medical reports, witness statements, etc. Scanning multiple documents into one file is okay. Attach up to five separate files,
each 4MB or less. Acceptable file types are PDF, TIF, JPG, BMP, and PNG.

Review and edit information before submitting. If you find an error after submitting, email the claims examiner with the correct information
or submit a revised form. To submit online, select “Revised” and enter the claim number. Data is not stored and will not re-populate the claim form. Re-enter
the required information and any changes to be made.

Download the completed PDF after submitting. Be sure to save a copy for your records. You cannot access this file after leaving the page.
Contact us if you forgot and need a copy.

Contact us. If you experience problems using the online form call Website Support at 208-332-2197 M-F, 8 a.m. to 5 p.m. MT. Call the Claims
Department at 208-332-2100 regarding information required on the form or the claim process.